U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Handoffs and Transitions
Safety and Medical Education
Device-related Complications (223)
Diagnostic Errors (197)
Identification Errors (115)
Discontinuities, Gaps, and Hand-Off Problems (589)
Fatigue and Sleep Deprivation (123)
Medication Safety (1226)
Medical Complications (674)
Nonsurgical Procedural Complications (109)
Surgical Complications (570)
Transfusion Complications (25)
Psychological and Social Complications (198)
Australia and New Zealand (141)
Central and South America (10)
North America (3850)
Clinical Guideline (6)
Journal Article (3609)
Newspaper/Magazine Article (538)
Press Release/Announcement (19)
Special or Theme Issue (66)
Web Resource (91)
Epidemiology of Errors and Adverse Events (1496)
Active Errors (905)
Latent Errors (531)
Near Miss (80)
Approach to Improving Safety
Quality Improvement Strategies (1127)
Legal and Policy Approaches (405)
Error Reporting and Analysis (1472)
Communication Improvement (1038)
Human Factors Engineering (617)
Specialization of Care (368)
Logistical Approaches (349)
Culture of Safety (597)
Technologic Approaches (729)
Education and Training (855)
Allied Health Services (7)
Health Care Providers (3063)
Health Care Executives and Administrators (3931)
Non-Health Care Professionals (1839)
Setting of Care
General Hospitals (1324)
Children’s Hospitals (147)
Specialty Hospitals (76)
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On the CUSP: Stop HAI.
Health Research & Educational Trust, MHA Keystone Center.
Tubing Misconnections Self Assessment for Healthcare Facilities.
Horsham, PA: Institute for Safe Medication Practices, Deerfield, IL: Baxter Healthcare; 2012.
Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.
The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.
Eliminating Catheter-Associated Urinary Tract Infections.
Chicago, IL: Health Research & Educational Trust; July 2013.
New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).
Oakbrook Terrace, IL: Joint Commission; May 17, 2011.
Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
Fakih MG, George C, Edson BS, Goeschel CA, Saint S. Infect Control Hosp Epidemiol. 2013;34:1048-1054.
Achievements in eliminating healthcare-associated infections awards.
Washington, DC: US Health and Human Services and Critical Care Societies Collaborative. December 7, 2010.
Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:726-731.
Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.
Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.
Administering a saline flush "site unseen" can lead to a wrong route error.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Infusing fun into quality and safety initiatives.
Foulk KC, Tocydlowski P, Snow TM, et al. Nursing. 2012;42:14-16.
Do clinicians know which of their patients have central venous catheters?: A multicenter observational study.
Chopra V, Govindan S, Kuhn L, et al. Ann Intern Med. 2014;161:562-567.
Parent willingness to remind health care workers to perform hand hygiene.
Buser GL, Fisher BT, Shea JA, Coffin SE. Am J Infect Control. 2013;41:492-496.
Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.
Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.
Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).
Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.
Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines.
Fuller C, Besser S, Savage J, McAteer J, Stone S, Michie S. Am J Infect Control. 2014;42:106-110.
Health Care–Associated Infections (HAI) Portal.
The Joint Commission.
Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.
Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.
Balancing "no blame" with accountability in patient safety.
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
A multidisciplinary approach to reduce central line–associated bloodstream infections.
McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.
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